The Many Faces of Binge Eating Disorder
By Amy Pershing, LMSW, ACSW
Binge eating disorder (BED) is endemic in our culture. BED is three times more common than all other eating disorders combined, more prevalent than breast cancer, HIV, or schizophrenia. Binge eating affects people across the life span, in all socioeconomic groups, races, sexual orientations, genders, and all body shapes and sizes. It is by far the most common eating disorder among men (40 percent of people with BED identify as male). BED is present in three to five out of every 10 people seeking weight-loss surgeries. Literally millions of people struggle with the disorder. Yet even with this prevalence, BED is still an eating disorder often missed in clinical and medical assessments. Research suggests that only 40 percent of those with BED will receive treatment in their lifetime (and this is among only those diagnosed). For many with BED, efforts to stop binge eating are short-lived, and resulting yo-yo weight losses and gains are common. By the time people with BED arrive in our offices for help, they are exhausted, hopeless, and ashamed.
I have treated BED for more than 30 years. In that time, I have deeply explored the adaptive roles binge eating plays in the lives of my clients. Among these roles, binge eating creates a temporary disconnection from pain or fear, and allows other feelings like anger and grief to be expressed with more psychological safety. A client of mine, Linda, says this: “Food thoughts and planning a binge gave me a safe harbor when I was afraid or lonely. It got me through my past, my divorce, a whole lot of pain I had no idea how to address.” Such a relationship with food brings respite from a psychological and somatic experience that seems impossible to withstand. Molly describes the experience of a binge this way: “The urge happens when I’m thinking about something upsetting or uncomfortable. My thoughts drift to what ‘bad’ foods I have to eat. It’s a seemingly innocent line of thought. Something like, Oh, what could make me feel better right now? And then the decision comes quickly and overwhelmingly. The energy shifts to something compulsive and shameful. Once I’ve committed to bingeing, I need to do it as soon as possible. The blinders come on, and as soon as I’m in the house, I’m reaching for whatever I can.” Binge eating is typically frenetic and impulse-driven, and seems impossible to waylay. As my client Katie notes, “It’s eating fast. Shoveling food in. It tastes so good. I want more. It’s taking another bite—and another, and another—while still chewing the first bite. I tell myself I deserve it. It’s been a long day. It’s late. I’m tired. I’ll exercise more, soon, tomorrow, next week. I’ll make up for it somehow.” Allen says this: “I know I am tired of performing, of getting everything right everywhere. Binge eating is a way to do nothing right. In a weird way, it makes me feel powerful for a moment. Then it comes crashing down, and I feel totally out of control.” Claudina describes it this way: “I first experience the urge to binge-eat physically. I start to feel anxious in my stomach. I feel a gnawing deep in my belly right above my belly button, but it’s not hunger—not physical hunger, anyway. It’s feelings of anxiety and self-doubt and worry. I think of it as a mini-tornado in my stomach, twisting and turning furiously and growing bigger and gaining strength until I make it go away with food.”
People with BED live myopic and diminished half-lives, often with the sense that some profound characterological weakness must be at the heart of their inability to change. In fact, as clinicians know well, many forces collide to create BED. Genetics, the biological impact of dieting and often severe food restriction, trauma of all kinds (including weight stigma), sociocultural oppression, and access to health care all can play a role.
In my clinical work with BED, I have found four precepts especially important to creating a platform on which recovery from this complex disorder can progress over time. These precepts promote the most critical components of successful treatment: depathologizing the client’s relationship with food, and empowering people to listen to themselves (and others) through a lens of curiosity, compassion, and strength.
Precept 1: Name and Treat Trauma
Research thus far suggests that up to 50 percent of people with binge behaviors have symptoms of post-traumatic stress disorder. In my experience, the rate is higher. For most of my clients, binge eating is a procedurally learned tool in coping with the somatic sense of danger in their environment. For some trauma survivors, the experience of being on “yellow alert” is part and parcel of existence. Most of my clients describe this sense as being “lifelong,” or even more telling, “just the way the world is.” Most of the roots of these feelings come from childhood. For many, expectations from important people were unreasonable, inappropriate based on age, or ill-defined and confusing. Joan recalls the experience of packing for a family vacation: “If you weren’t in a state of Boy Scout readiness at all times, it was implied that the ceiling would collapse, the rug would be pulled out from beneath you, you will get hopelessly lost (and probably kidnapped). No recourse. Nobody’s going to help you.” There was no room for error, and the message that danger lurked both inside and outside the family is clear. Karen says it well: “I was unaware of the unwritten/unspoken rules and always scrambling to find safety, like buckling my seat belt after the crash. It became second nature to look for clues in interactions that could help me buckle up before impact. I read tone of voice. I searched body language to find out what was expected. I read articles in Good Housekeeping, trying to figure out how to perfect my actions in doing chores.” The most critical task: Avoid failure at all costs, or relationships will suffer or end. Living with this orientation triggers our most primitive survival skills. Going to food provides relief from this somatic experience of threat. The more a binge is about soothing or distraction, or associated with relief, safety, or pleasure, the more powerful the drive to do it becomes. To suggest a person simply stop the behavior is to completely misunderstand the ways we are literally wired for survival above all else. BED recovery then must allow for trauma resolution and healing; without this, change will not last.
We must also be aware of the impact of sociocultural trauma for our clients. Recall that the definition of trauma is experiencing an overwhelming amount of stress that exceeds one’s ability to integrate/resolve the emotions from the experience. Trauma may result from a single distressing experience or recurring events of being overwhelmed that can occur over weeks or years. The person struggles to cope by developing strategies like binge eating. Forces such as weight stigma, poverty, racism, homophobia, ableism, and access to health care sadly fit this description. Such effects must be addressed in the clinical milieu. If not, we risk both empathic misattunement and interventions that ignore the need for systemic, not psychological, change.
Precept 2: The Body Finds Its Way
Although not usually defined as such, BED is often also a disorder of restriction and food obsession. Most clients with BED have significant histories of dieting and/or excessive exercise. As with any eating disorder, behavioral weight loss as an intervention is essentially prescribing a symptom. It is ineffective, damaging long term (due to yo-yo weight changes), and is not predicated on good science regarding health or longevity.
Diet culture automatically equates thinness to health. One of the principles driving the $65 billion weight-loss-related industry is the notion that fat is inherently unhealthy; the implication is to be thin is best, no matter what a person must do to get there. However, a growing body of research is challenging this paradigm. Does obesity actually cause ill health, result from it, both, or neither? Does weight loss (if it’s even possible) lead to a longer, healthier life for most people? Are the methods for weight loss in and of themselves costlier to health than any weight lost? In fact, studies from the Centers for Disease Control and Prevention repeatedly find the lowest mortality rates among people whose body mass index puts them in the “overweight” and “mildly obese” categories. And recent research suggests that losing weight doesn’t actually improve health biomarkers such as blood pressure, fasting glucose, or triglyceride levels for most people; in fact, yo-yo weight changes may make them worse.
Regardless, according to the dominant paradigm, thinner means healthier, and healthier in many ways equates to being a better person—even though current health statistics data tells us we cannot assume the nature of the impact of weight on health for any given person. But if it were possible to be healthy and happy at many sizes and weights (and if we did not moralize health), a $65 billion per year diet industry would have a tough time surviving. Body shame would be much harder to sell.
Despite this research, sales of diet programs remain brisk. The Boston Medical Research Center indicates that approximately 45 million Americans diet each year, with an average of five attempts per dieter. Diet companies begin grooming new dieters by targeting people as young as age 8. And yet, diets fail at an astonishing rate. This isn’t breaking news; doctors and researchers know that the holy trinity of “obesity” treatments—diet, exercise, and medication—don’t work. They also know that yo-yo dieting (which is almost unavoidable given the failure rate) is linked to, among other things, heart disease, insulin resistance, higher blood pressure, inflammation, and, ironically, long-term weight gain. Still, they push the same ineffective treatments, insisting that they will make you not just thinner, but healthier. In reality, 97 percent of dieters regain everything they lost and then some within three years. Your chance of keeping weight off for five years or more is about the same as your chance of surviving metastatic lung cancer: approximately 5 percent. “Obesity” research fails to reflect this truth, in part because it rarely follows people for more than 18 months. This makes most weight-loss studies disingenuous at best and downright deceptive at worst. To add insult to injury, dieters blame themselves, not dieting, for their virtually inevitable string of “failures.” This reinforces already present trauma narratives of unworthiness and unlovability.
Equating health to weight to moral fiber profoundly increases the shame around binge eating. While there are many psychological and cultural factors at play in BED, we must also note that diet “failure” itself often plays a causal role in maintaining the cycle of binge eating. Dieting alone is not sufficient to causeBED (many people diet and don’t develop BED); however, dieting affects not only our psyches by adding even more narratives of failure, but also our bodies. In very specific ways, dieting powerfully contributes to the development and maintenance of BED. Let’s consider just three of the important biological processes that make dieting a very ineffective and damaging strategy to stop binge eating. First and foremost, our bodies don’t biologically know the difference between a diet and a famine. While one may be intentional and the other is clearly not, they both affect our body in the very same way: as an immediate threat to survival. In response to such a threat, our body reacts with a number of essential and inevitable processes. First, when we are hungry for a sustained period, our brain responds by literally making us think more about food. Study after study shows us that regardless of the cause, when we are hungry, our thoughts turn naturally and unerringly to finding nourishment. In fact, research shows that our brain actually increases the “reward value” of foods in two ways: by making our taste buds take longer to reach the point of signaling satiety and by reducing the release of fullness hormones while increasing the release of hunger hormones. Bottom line: We are fundamentally wired to become “obsessive” about food when we are hungry and to experience hunger more intensely. Thus, very high rates of weight regain on diets are not surprising; our body fights food restriction efforts at every turn. If it did not, we would not have survived as a species.
In addition, our bodies do not like to change. If a particular behavior is associated with physical or psychological survival (whether accurately or not), our body resists changing it. Since adequate nourishment is clearly connected to survival, weight loss is perceived as a threat. In other words, our bodies seem to be strongly wired to hang on to weight and to be most stable at a specific weight range. This is known as “set point theory,” and the evidence in its favor is compelling. According to this theory, our bodies, based on genetics, epigenetics, and our immediate environment, have a weight range at which they are programmed to function optimally. Set point theory holds that one’s body will fight to maintain that weight range if it is threatened. And it will fight especially hard if there is weight loss, as opposed to weight gain. Thus, as the threat (be it famine or diet) continues, the dieter’s body becomes increasingly efficient. Weight loss becomes harder and harder to achieve (the “dieter’s plateau”). Weight is far more easily regained when the body is more efficient, even beyond its set point weight. It is as though our body learns to anticipate famine in the future and prepares accordingly. Indeed, dieting proves to be the best way to gain weight. For those with BED, the powerful psychological drives to go to food are reinforced by the protective mechanisms of the body itself. Thus, recovery must not only address the psychological and cultural causes of BED, but also provide a whole new paradigm for how we understand food and make choices about how to best feed our bodies.
Behavioral weight loss as a treatment goal also goes against creating a safe space to learn and heal interoceptively. Our job as clinicians is to offer as few guardrails as possible to allow clients the space to determine what works best for their unique body. Learning to increasingly eat from body cues, overall body awareness, basic nutritional needs, and desire in the moment serves each client best. This approach requires access to a diverse array of foods; clinicians serving impoverished populations have the additional burden of helping their clients try to develop interoceptive awareness when adequate food options may not even be available.
Precept 3: Redefine Recovery
There are many competing ideas about what constitutes “recovered” from BED or if it is even possible to consider the work of recovery to have an end point at all. I find that people far along in the journey use both “in recovery” and “recovered,” and while the semantics differ greatly, we all seem to be naming a similar place. For most people with BED, eating from trauma activation, anxiety, or the drive to dissociate remains in the coping toolbox for a very long time. This is not relapse; it is the nature of doing the deep work of healing trauma and histories of food restriction. Typically, the frequency and severity of binge episodes lessen significantly over time. But it is not the work of recovery to develop a relationship with food and body that suggests an eating disorder never existed. We cannot wipe away the truths of our experiences as if we had lived different lives.
Many of my clients far along in recovery actually develop a kind of gratitude for their eating disorder. While they would certainly never wish for such a relationship with food, there is a way the symptoms of binge eating and body hate brought them, eventually, to treatment. This is not the feeling for everyone in eating disorder recovery; for some, adamant rejection of the voice of “ED” is a critical part of long-term change. For many with BED, however, binge eating has been such a source of shame that to reject the disorder compounds the shame. It can feel like yet another rejection of the reality of their story, and a failure of willpower whenever they overeat. Since BED recovery may always include some overeating, this approach keeps shame narratives alive.
I have found that it is healing to have gratitude and compassion for the role food has played; indeed, this kind of stance toward BED often makes for the best chance at a peaceful relationship with food and body. “Bingeing was a trail of breadcrumbs for me,” notes Anna. “I’m not sure how I would have had the drive to heal from my past without having something so distressing I had to confront.” Harry writes, “Without binge eating, I don’t think I could have warned myself something big was missing from my life.” From Nicole: “Most of my life, I was hungry. I now know that eating was not a sign of failure.”
Until compassionate self-care is the ultimate goal, not simply changing eating patterns, recovery will not last. If motivation for change is predicated on the need to “fix” what is “wrong” with one’s body, it is a motivation based in shame. As such, it will not allow us to really hear our needs and be able to effectively address them. Recovery measured in pounds lost maintains the idea of conditionality of acceptance and, ultimately, of our sense of safety and lovability in the world. Recovery should provide our clients with far better goals than weight loss (which may or may not occur for any individual); it should provide a path for being authentic, body and all, in the world.
Precept 4: Advocacy Heals
The deep work of recovery from BED is an act of revolution. In personal, interpersonal, and cultural ways, healing calls for courage, tenacity, and commitment. It requires truth telling and holding one’s own voice with others in a cultural milieu that is reluctant to change. Becoming an advocate for change, in whatever form, can be a powerful tool for healing both self and community.
Many of us who have experienced BED learned to keep away from sharing our stories. We learned to feel fear or shame about what is closest to our hearts. As my clinical colleague Theresa Chesnut suggests: “Recovery is going from an early life of lived vulnerability toward needs and desires, to believing we must disconnect from our self to be loved, to moving back to embracing and living in vulnerability.” Recovery often requires a 180-degree turn from what feels true to find what is true. Sharing that truth heals.
The work of recovery is a political act. Trusting our own body is a rejection of a very dominant paradigm, one that makes billions of dollars from building shame, internal distrust, and disconnection from our physical and psychological truths. Insisting on making our own decisions for our bodies without weight loss as the inherent goal, calling out oppressive or shaming ad campaigns, or refusing to participate in the latest “Weight Watchers Work Challenge” because the data does not support its efficacy are courageous things to do. Truth telling about the myriad intersectional ways in which our voices have been silenced, by weight stigma, misogyny, racism, homophobia, poverty, and ableism, is a fundamental part of the journey home. To listen well by meeting ourselves with compassion and kindness (and offering the same to others) goes against many of our most deeply held beliefs about competition and what makes people “strong” and “respectable.” Refusing to think of BED as simply part of the alleged “obesity epidemic” or as a willpower issue to be treated with yet another attempt at weight loss is an act of defiance, as well. Choosing not to participate in “weight talk” or fat shaming is rarely comfortable. Rejecting images that shame our bodies, or the bodies of our daughters and, increasingly, our sons, is an empowering, gutsy act with far-reaching consequences for healing. Indeed, it is more sustaining of recovery than almost anything else we do. As Audre Lorde says so beautifully in “The Transformation of Silence into Language and Action”: “We can learn to work and speak when we are afraid in the same way we have learned to work and speak when we are tired. We have been socialized to respect fear more than our own needs…the weight of that silence will choke us.”
Recovery from BED cannot happen in a vacuum; the cultural mores that oppress people, the glorification of economic success and being “busy,” and the focus on appearance and devaluing of body wisdom must be addressed in our clinical paradigms. Any model that does not take both oppression and indigenous ways of healing into account reinforces shame narratives and blames the victim. For example, while cognitive behavioral work may be empowering to some clients, it may feel threatening or hierarchical to others. Or “body positivity” for some might feel disingenuous in its typical insistence of keeping value on appearance, but it might be profoundly liberating for others. The client must be the expert; it is our job to bear witness and adapt.
Our job as clinicians treating BED is a complex one. We are empowering our clients to listen to themselves through a lens of curiosity, compassion, and strength. We must also prepare them to walk out of our offices into an environment that reinforces the language of shame. It is the heart of our work to help our clients honor tools of survival like binge eating—then, as we are able, to help them move from surviving to thriving, healing ourselves and our communities.
About the author:
Amy Pershing LMSW, ACSW is the Founder of Bodywise BED Recovery Program, and a Director of the Center for Eating Disorders in Ann Arbor. She is the co-founder of Pershing Turner Consulting, which offers training to clinicians treating BED nationwide. Amy is also the instructor for the course “Binge Eating Disorder: Clinical Interventions to Treat Underlying Trauma, Body Shame, and the Binge/Diet Cycle” offered nationally by PESI.
Based on 30 years of clinical experience, Amy has pioneered a treatment approach for BED that is strengths-based, incorporating Internal Family Systems and somatic trauma techniques. Her approach also integrates “attuned” eating and movement and a “health at every size” philosophy. Amy offers two- and three-day Intensives for those in recovery, and is the creator of “Hungerwise™,” a 9-week program for ending chronic dieting and weight cycling offered jointly with with St. Joseph Mercy Health System in Michigan. In 2020, Hungerwise™ will be available nationally online.
Amy lectures internationally and writes extensively on the treatment of BED and her own recovery journey for both professional and lay communities. She has been frequently featured on radio, podcast, and television speaking about BED treatment and recovery, relapse prevention, weight stigma, and attuned eating and movement. She is the winner of BEDA’s 2016 Pioneer in Clinical Advocacy award, and has served on a variety of professional boards. She is the Past Chair of the Binge Eating Disorder Association (BEDA), and is a clinical consultant for the National Eating Disorders Association (NEDA). She is the author of the book Binge Eating Disorder: The Journey to Recovery and Beyond. Amy maintains her clinical practice treating BED in Ann Arbor.
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